Legal/Ethical
A client with bipolar disorder is asked to sign a consent form for Lithium while in a manic state. What should be assessed prior to asking the client to sign this form?
Decision-making capacity.
Rationale: Consent is only valid if the client has capacity, mania may impair judgment of the client.
A client with psychosis is paranoid and refuses to eat, he states the food is poisoned. What is the best intervention by the nurse?
Offer sealed pre-packaged foods
Rationale: This action supports the client's need for nutritional intake, respects the client's feelings of paranoia and facilitates trust.
Mental health refers to emotional well-being, whereas mental illness involves a disturbance in everyday functioning and the ability to deal with stressors. True of False.
True
A client with acute psychosis begins rapidly pacing and clenching their fists. What can the nurse do to maintain the safety of the milieu?
Offer a quiet room or area and assess the client to figure out what is triggering them
Rationale: Offering a quiet space and assessing triggers helps to de-escalate growing agitation while maintaining safety.
The nurse develops a goal stating, "Mr. Smith will verbalize two coping strategies for anxiety by the end of the shift." Which part of nursing process does this statement represent?
Planning
Rationale: Setting measurable, time-bound goals is part of the planning phase.
The nurse understands Peplau's primary goal of the orientation phase is to:
Identify the needs of the client and establish trust
Rationale: Orientation = trust building + identifying problems
A client refuses to attend group therapy. The nurse threatens to restrict phone privileges if they do not go to group. This is an example of:
Assault
Rationale: Threatening harm or punishment to gain compliance constitutes assault. The client may be reminded there are other rewards for attending group, but they cannot be threatened or punished because they do have the right to refuse.
The client states "The television is sending me secret messages." The nurse recognizes this as what type of symptom?
A positive symptom
Rationale: Delusions (including ideas of reference) are positive symptoms -- any new symptom that distorts normal functioning
The nurse advocates for equal access to mental health services for clients regardless of their socioeconomic status. This action reflects which ethical principle?
Justice
Rationale: Justice involves fairness and equitable access to care.
Explaining all procedures before touching the client is an important part of trauma-informed safety in the milieu. True or false
True
Rationale: Explaining procedures promotes control and reduces re-traumatization.
A nurse evaluates a client's progress and determines that the goal of reducing panic attacks from daily to once a week has not been met. The nurse's next action is to revise the interventions and collaborate with the treatment team. True or False
True
Rationale: When goals are unmet, the nurse revises the interventions and collaborates with the treatment team to revise the plan of care.
A nurse uses open-ended questions to:
Encourage response
Rationale: Closed ended questions allow the client to respond in one or two words. Open-ended questions encourage the client to provide more information.
A nurse who is admitting a client to the behavioral health unit fails to complete the suicide risk assessment. Later the client is in her room alone and attempts suicide. The omission by the nurse is an example of:
Negligence
Rationale: Negligence occurs when the nurse fails to meet the standard of care, resulting in harm to the client.
A client with schizophrenia presents with mutism, flat affect, and social withdrawal. The nurse understands these are what kind of symptoms?
Negative Symptoms
Rationale: These are negative symptoms (anything the patient has lost or changed) i.e. affect, speech, etc. The most therapeutic approach is being present without pressure and offer simple, easy to understand directions.
The nurse chooses the least restrictive intervention for a client experiencing anxiety. This reflects which ethical principle?
Beneficence
Rationale: Beneficence involves promoting well-being and choosing interventions that support the clients best interest.
A client on an inpatient psychiatric unit is scheduled for ECT but appears confused and unable to explain the procedure. It is ok to proceed with the treatment as it has been ordered by the provider and will eventually help the client. True or False
False
Rationale: The nurse should notify the provider that the informed consent may not be valid. Informed consent requires capacity, confusion invalidaties consent and must be reported to the provider.
True
Rationale: Refusing food for 24 hours increases risk for dehydration and metabolic imbalance.
A client tells the nurse "You remind me of my daughter. I feel like I can trust you more than the others." The nurse recognizes this as:
Transference
Rationale: The client is projecting feelings from a past relationship onto the nurse.
A nurse fails to follow inform the provider of a critically elevated lithium level. The client develops toxicity. This is an example of:
Malpractice
Rationale: Malpractice is professional negligence that results in harm.
A client reports to the nurse that he is hearing voices telling him, "You are worthless." The nurse observes the client turning his head and whispering. What is the nurses next step?
Assess the client for command hallucinations
Rationale: Auditory hallucinations are a positive symptom, determining if the presence of command hallucinations ensures safety as they may be commands to inflict harm on self or others. Safety is the priority.
Rationale: Exploring and validating concerns help reduce internalized stigma and builds trust in the nurse-client relationship.
Continuous 1:1 monitoring.
Rationale: Continuous 1:1 monitoring ensures the client is safe while in restraints.
During the implementation phase of the nursing process, providing a quiet environment with minimal stimuli is an appropriate intervention for a client experiencing severe anxiety. True or False.
True
Rationale: Reducing environmental stimuli helps stabilize severe anxiety so deeper exploration of triggers can take place.
A client asks the nurse for personal details about their life. An example of the most therapeutic response by the nurse is:
"I rather not talk about myself. Let's focus on you."
Rationale: Maintains boundaries while redirecting the client.
Duty to warn
What is the risk of taking Clozapine that warrants close monitoring of the CBC.
Agranulocytosis
Rationale: Clozapine can cause neutropenia or agranulocytosis.
The nurse reflects on their own assumptions about clients with substance use disorders. This is an example of:
Self-awareness
Rationale: Self-awareness is essential for recognizing and mitigating personal biases.
A nurse applies restraints after a client attempts to strike another patient. The next action of the nurse, immediately after the restraints are secured is to assess the client's circulation, respiratory status, and psychological comfort. True or False.
True
Rationale: Immediate assessment ensures the restraints are safe and not compromising the airway, breathing, circulation, or emotional well-being.
A client with schizophrenia has been taking haloperidol for 3 weeks for command hallucinatioins. Which assessment finding would indicate to the nurse the treatment is effective?
Decrease in command hallucinations
Rationale: Reduction in positive symptoms (Hallucinations, delusions) is the primary indicator for effectiveness of an antipsychotic.
A client tells the nurse, "I don't want to talk to you." What would be a therapeutic response from the nurse?
"It sounds like you are not ready, and that's okay. I will sit with you quietly.